Cite as: Vargas MPB, Restrepo-Garcés CE. Gaps in access to interventional pain procedures in Latin America: a call for equity in chronic low back pain management. ASRA Pain Medicine News 2026;51. https://doi.org/10.52211/asra080126.008.

Collaborative Series

A Collaborative Article between ASRA Pain Medicine and LASRA

Chronic low back pain, including that associated with spinal stenosis and presenting as neurogenic claudication or radicular pain, remains a leading cause of disability worldwide.¹ Although multiple evidence-based interventional and non-interventional treatment options are available, access to comprehensive pain management remains highly variable across regions. In Latin America, barriers related to healthcare infrastructure, specialist availability, reimbursement policies, and resource allocation often limit access to interventional pain therapies. As a result, significant gaps persist between evidence-based recommendations and real-world clinical practice, potentially affecting patient outcomes.

Surgical intervention is generally reserved for cases of persistent pain refractory to conservative and interventional measures, and more urgently indicated in the presence of neurological deficits or so-called “red flag” signs.^2,3 For key pain generators—posterior elements such as the facet joints, anterior vertebral pain sources (ie, vertebrogenic pain), and discogenic components—specific interventions have been developed and validated.¹ One notable example is the Minimally Invasive Lumbar Spinal Stenosis Treatment 2.0 algorithm (MIST 2.0), which targets symptomatic spinal stenosis through minimally invasive techniques.⁴

Emerging evidence suggests that interventional treatment of anterior spinal pain generators, including vertebrogenic and discogenic pain, can significantly alleviate symptoms. Procedures such as basivertebral nerve ablation have demonstrated efficacy in multiple randomized controlled trials.^5-7 Despite this, the implementation of such interventions is severely limited in many countries, particularly in Latin America, where these technologies are often unavailable.

Current guidelines support the use of medial branch blocks followed by radiofrequency ablation for facet-mediated pain, as well as selective nerve root blocks, transforaminal epidural injections, and pulsed radiofrequency procedures for radicular pain—often considered before progressing to surgery.^8-11 Unfortunately, the final stages of these interventional algorithms remain unavailable in many Latin American settings because of limited access to the required devices.

This results in notable “gaps” in the interventional algorithm, particularly for:

1. Vertebrogenic Pain: Current guidelines recommend basivertebral nerve ablation for appropriately selected patients with vertebrogenic pain and modic type I or II endplate changes on MRI.⁷ However, this technology remains unavailable in large parts of Latin America. Consequently, patients are typically managed with pharmacologic therapy, rehabilitation, spinal injections, and in selected cases, surgery despite the limited ability of these approaches to specifically target the underlying pain generator.
2. Spinal Stenosis with Neurogenic Claudication: Following comprehensive conservative management, including lumbar epidural steroid injections, physical therapy, and pharmacologic treatment, procedures such as percutaneous image-guided lumbar decompression and interspinous spacers may be considered for select patients. According to guidelines published in the Journal of Pain Research, their use is determined by factors such as spinal instability, the presence of spondylolisthesis, and post-laminectomy status.^12,13 However, these technologies remain unavailable in many Latin American countries. Consequently, management is often limited to continued conservative care, repeated epidural steroid injections, or surgical decompression, leaving few intermediate treatment options for patients who are poor surgical candidates or wish to avoid surgery.
3. Sacroiliac Joint Pain: Although sacroiliac joint radiofrequency procedures can be performed in some Latin American centers, more advanced interventions, including cooled radiofrequency (Cooled-RF) and implantable stabilization systems, remain largely inaccessible across the region.¹⁴ Similarly, sacroiliac joint fusion technologies are either unavailable or available only in a limited number of specialized centers. Consequently, treatment is often restricted to physical therapy, intra-articular corticosteroid injections, and conventional radiofrequency ablation. While these modalities may provide symptomatic relief, the lack of access to more advanced interventions limits the range of evidence-based treatment options available for patients with refractory sacroiliac joint pain.
4. Peripheral Nerve Stimulators: Peripheral nerve stimulation systems have emerged as promising treatment options for both peripheral pain syndromes and selected cases of axial low back pain. ¹⁵ However, these technologies remain largely unavailable throughout Latin America. Similarly, limited access to restorative neuromodulation systems targeting multifidus dysfunction creates an additional therapeutic gap for patients with chronic non-specific low back pain.¹⁶ As a result, management in the region is typically limited to pharmacologic therapy, exercise-based rehabilitation, and, in carefully selected cases, spinal cord stimulation. This lack of access limits access to minimally invasive neuromodulation strategies that may offer alternatives before escalation to more invasive treatments.

These access limitations are not isolated to these indications. Recent guidelines on early spinal cord stimulation implantation for patients with treatment-naïve chronic low back pain^17,18—also published in the Journal of Pain Research—raise the question: Can such recommendations be realistically followed in resource-limited settings? More broadly, should international guidelines acknowledge resource-constrained settings such as those found in Latin America, or should implementation await broader access to the requisite technologies?

Educational initiatives led by the Latin American Pain Society and other regional organizations represent important steps toward narrowing these disparities. Through scientific meetings, educational programs, hands-on training opportunities, and collaborations with international societies, these initiatives help disseminate knowledge regarding emerging interventional therapies and promote the development of regional expertise. However, education alone is insufficient.

From our perspective, equity does not necessarily imply immediate access to every emerging technology in every healthcare setting. Rather, it involves developing regional referral centers, structured physician training programs, regulatory pathways for device approval, and reimbursement mechanisms that enable eligible patients to access evidence-based interventions. A feasible pathway may include pilot implementation projects at high-volume centers, regional outcome registries, local cost-effectiveness analyses, and reimbursement frameworks that facilitate access to evidence-based technologies. Without such coordinated efforts from clinicians, scientific societies, regulators, payers, and industry partners, many patients in Latin America will continue to be excluded from therapies that are increasingly considered standard components of contemporary interventional pain management. Bridging this gap is not merely a matter of technological adoption, but of advancing equity in evidence-based pain care.

References

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